Health Care Reform

Have Questions

View commonly asked questions and who to contact for more information

Why should I have health care coverage?

While no one plans to get sick or hurt, most people need medical care at some point. Health plans cover these costs and protect you from very high medical expenses.



If I have Medicare, Medicaid or an employer sponsored health plan, do I have to buy coverage on the Marketplace?

You are considered covered  if you have minimum essential coverage, which includes Medicare, Medicaid, Children’s Health Insurance Program (CHIP), any job-based plan, any plan you bought yourself, COBRA, retiree coverage, TRICARE, VA health coverage, or certain other coverage.

If you are eligible for job-based coverage, you can consider switching to a Marketplace plan; however, you will not qualify for lower costs based on your income unless the job-based coverage is unaffordable or does not meet minimum requirements. You may also lose any contribution your employer makes to your premiums.

If you have health coverage through Medicare, the Marketplace won’t have any effect on your Medicare coverage. Your Medicare coverage is protected; any existing Medicare coverage will not be reduced or taken away.  You do not need to replace your Medicare with coverage on the Health Insurance Marketplace.



What is my penalty for not joining?

Those who do not have or do not obtain coverage that qualifies as minimum essential coverage will pay a tax penalty. The amount of the penalty for an individual is phased-in as follows:

  • In 2016, the penalty is $695 per adult ($347.50 per child) with a maximum of $2,085 for a family or 2.5% of taxable income, whichever is greater.

  • In 2017, the penalty is $695 per adult ($347.50 per child) with a maximum of $2,085 for a family or 2.5% of taxable income, whichever is greater.   


It’s important to remember that if you pay the penalty, you will not receive any health plan coverage. You will still be responsible for 100% of the cost of your medical care.



Are there exceptions from paying a penalty for not having health care coverage?

Yes, you may qualify for an exemption if:

  • You are uninsured for less than 3 months of the year;
  • The lowest-priced coverage available to you would cost more than 8% of your household income
  • You do not have to file a tax return because your income is too low;
  • You are a member of a federally recognized tribe or eligible for services through an Indian Health Services provider;
  • You are a member of a recognized health care sharing ministry;
  • You are a member of a recognized religious sect with religious objections to health coverage, including Social Security and Medicare;
  • You are incarcerated, and not awaiting the disposition of charges against you; or
  • You are not lawfully present in the U.S.


To apply or learn more about an exemption, call the Health Insurance Marketplace at 1-800-318-2596; TTY: 1-855-889-4325, or visit www.healthcare.gov/exemptions



How do I find out if I qualify for a subsidy?

When you complete your application through Healthcare.gov, you will find out how much you can save and what coverage you qualify for. Total Health Care does not determine the Advance Premium Tax Credit (APTC) or Cost Sharing Reduction (CSR). To see if you qualify for a subsidy, you can use a subsidy calculator to determine what range of a subsidy you qualify for.

Kaiser Family Foundation Subsidy Calculator



What factors affect Health Insurance Marketplace health plan premiums?

Health plan premiums are affected by five factors: age, family size, location, tobacco use, and plan category.  Your health status (including any pre-existing conditions) and your gender do not impact health plan pricing.



When do I have to sign up?

Annual open enrollment runs from November 1, 2017 – December 15, 2017.



Can I enroll after the open enrollment period?

Yes, certain qualifying life events can make you eligible for a Special Enrollment Period. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).



What are the plan levels?

Health plans in the Marketplace are primarily categorized into 4 “tiers” or “levels” based on the percentage the plan pays of the average overall cost of providing essential health benefits to members, commonly referred to as the actuarial value (AV).

medals_chart_v02_b


For example, if a plan has an actuarial value of 70%, on average, the member is responsible for 30% of the costs of all covered benefits.



What are “essential health benefits?”

Essential health benefits are a comprehensive package of items and services that all health plans must offer, including:

  1. Ambulatory patient services (outpatient care you get without being admitted to a hospital);
  2. Emergency services;
  3. Hospitalization (such as surgery);
  4. Maternity and newborn care (care before and after your baby is born);
  5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy);
  6. Prescription drugs;
  7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills);
  8. Laboratory services;
  9. Preventive and wellness services and chronic disease management; and
  10. Pediatric services.


Do I have any cost-sharing for preventive services?

Preventive services are provided without charging a copayment or coinsurance when delivered by an in-network provider. This is true even if you haven’t met your yearly deductible.



Does Total Health Care offer adult and child dental benefits?

No, Total Health Care does not offer dental coverage.   You can purchase a stand-alone dental benefit on or off the Health Insurance Marketplace at www.healthcare.gov

Dental coverage for children is an essential health benefit.  It is not an essential benefit for adults.



Who do I contact for more information?

For more information on Total Health Care plan options, call our Customer Service Department at 1-800-826-2862. TTY users should call 1-800-349-3777.

For more information regarding the Health Insurance Marketplace, call 1-800-318-2596. TTY users should call 1-855-889-4325.

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